Commonly Missed Things in chronic pain
Commonly Missed Things in chronic pain
The worse problem area would have to be various assessments done along the way, finding “nothing” wrong with the patient. There is a litany of pain problems missed on assessments. If I only saw a patient for a brief assessment, I would make, to a certain degree, the same mistakes. Seeing a patient for only a short period of time only gives one an impression of their problems – not a definitive analysis.
Sorting out a patient’s problems could take months of work, unlayering by removing certain problems to find where all the pain sources come from.
Case in point – I have a gentleman with pervious neck and back surgery. I have been treating him for post-laminectomy syndrome (failed back) but have found over time that the right Quadratus Lumborum flank muscles is quite spastic. Nearby is a hip crest harvested (for neck surgery) bone donor site scar. Injection of that nerve entrapment in that scar has relieved the spasm on that side – though now other factors are now becoming more obvious.
Removing some problems so others are obvious can take months or longer. Clearly, patients need to be given the benefit of the doubt that something is wrong and treated accordingly. When I make a problem list with someone in chronic pain, it is usually over ten items long. Clearly a problem can no longer be just “cervical radiculitis for example. This causes myofasical trigger areas to grow in adjacent areas, facets and discs to undergo more strain as a result; tightened muscles to form entrapments (occipital neuralgia entrapment in neck), headaches to become apparent, and lack of sleep can generalize the pain elsewhere.
It amazes me how in a society where people have to be given the benefit of the doubt, this rule is not enforced in WCB. – Why –because cutting costs is the primary concern. I am not saying this is necessarily malicious but involves a pervasive negative attitude to chronic pain sufferers in general.
Some of these missed diagnosed conditions have been known to be missed for some time. It has not changed:
Psychosomatics 1993; 34:494-501
Overlooked physical diagnoses in chronic pain patients involved in litigation
NH Hendler and JG Kozikowski
Mensana Clinic, Stevenson, MD 21153
This study followed the course of 60 chronic pain patients, from referral to a pain diagnostic center through the formulation of complete discharge diagnoses. The most common referral "diagnoses" were really descriptions or vague explanations, such as "chronic pain," "psychogenic pain," "cervical strain," or "lumbar strain." The most commonly missed diagnoses were 1) myofascial disease, 2) facet disease, 3) peripheral nerve entrapment, 4) radiculopathy, and 5) thoracic outlet syndrome. Seventy percent of the laboratory studies ordered by the clinic had significant abnormalities. The authors determined that the overall rate of inaccurate or incomplete diagnosis at referral was 66.7%.
from:
article here
“Complex patients especially suffer from inadequate diagnosis and treatment. In a study of 60 chronic pain patients, the Mensana Pain Clinic and Johns Hopkins University Medical Center, found that the group required an additional 276 medical tests before physicians could reach a diagnosis. Seventy percent of the new tests showed abnormal findings. Upon referral, 66.7% of the patients had incorrect diagnoses, of which 41% were vague descriptors such as "failed back syndrome", "chronic pain", "psychogenic pain" or "muscle strain" instead of a medical diagnoses. Remarkably, 50% of the 60 patients needed additional surgery.28 …The Mensana study did not mention case managers, but by observation, one must wonder if case manager interference contributed to the problems. “
Reliance on MRI’s and such for deciding that “nothing is wrong” is criminal because many problems do not show up on these studies.
Case in Point – Lady was having leg weakness and pains. Had investigations including MRI and was told it was all in her head. She saw various physicians who picked up on previous “nuts” diagnosis and gave her a similar opinion. After several years and progression of her weakness and pain, some specialist reluctantly redid her MRI which demonstrate Syringomyelia – a cyst in the spine that can be painful and debilitating. This condition often comes with a brain herniation problem but again MRI tests were “negative”. These tests were reviewed by a specialist in the States who did find problems on several films. He suggested a CSF brain fluid study – this was reported as negative though the US specialist determined there was NO flow at all. A compassionate neurosurgeon reluctantly went in to do surgery “at the patient’s insistence” and was abhorred by the damage he saw in the base of the skull – all with normal MRI findings. This lady had deteriorated to being in a wheelchair with severe pain; she is now walking with a can.
On a similar vein:
Pain Res Manag. 2006 Autumn;11(3):197-9.
Whiplash injuries can be visible by functional magnetic resonance imaging.
Johansson BH
(presented with permission)
THIS MUST BE READ TO BE BELIEVED
Several cases of whiplash “normal” with normal MRI. Enhanced “fMRI” showed horrendous damage – for example - “There was a displacement of structures by scar tissue related to the dens. Rotation of his head brought the scar tissue into contact with the spinal cord. The dens-related capsule showed serious injuries as well as lesions in the capsules of the lateral atlantoaxial joints, with scar tissue and signs of chronic instability. The alar ligaments showed signs of injury and scar tissue."
There are only a few fMRI machines in Canada and none in Saskatchewan.
Some common missed: (also whiplash as seen from above case)
1) Subtle Nerve root irritation – It has now been shown that spinal nerve root symptoms are more a chemical reaction to irritants released from the disc. As A matter of fact, torn discs without any protrusion at all can irritate nerve roots on the side of the tear enough to cause evidence of nerve damage as well as sciatica like pains:
Pain. 2006 Sep 7; [Epub ahead of print]
Chemical radiculitis.
Peng B, Wu W, Li Z, Guo J, Wang X.
This phenomenon was noted for years ago by Dr. C. Gunn when working for WCB in BC
In back pain patients, he found multiple knots down the leg were all innervated by the same nerve root level and took almost as long to heal as entrapped nerves.
Now they cases are often the following scenario:
Initially there may be some numbness or shooting pain down arm or leg. Usually this is subtle. This will improve to just leave knots down the arm or leg that just don’t seem to what to go away. I would say this is chronic low grade nerve root irritation. How does one know?
Some of these cases I have injected with Enbrel, which inhibits the irritating nerve compound
- symptoms will subside some for awhile - needs two shots but cannot afford. (and that has been confirmed by “one” shot studies.)
Case in point – Subject early 20’s has a car accident. Initially there is neck pain with subtle shooting down arm relieved by doing nerve root releasing exercises called MacKenzie exercises. He is left with shoulder tip pains probably left by the continued chemical irritation that just don’t want to go away. This however would be considered a trivial injury and the fact it started with nerve root damage would be forgotten.
Now that it is understood that it is a disc released chemical reaction of the nerve roots, there is no need for heavy pressure on a disc. For years, insurers have been saying – well there is only minimal disc pressure on the nerve root on MRI/CT - that doesn’t mean anything. I am ashamed to now realize that was just a scam and this people were still a major problem with minimal compression. Then there is the case of the bulging disc. If torn disc not extruding can cause that much damage, then a bulging disc can do the same – how can you tell if it is important? -well it would hurt but insurers don’t see it that way - it’s just a bulging disc- lots of people have it – well lots of people are not in pain in that area.
2) Thoracic outlet syndrome – this is a very pervasive disease with long term morbidity. There was problems diagnosing it years ago:
Some years ago an SGI case went through a tertiary assessment. She had the worst case I ever saw –she could cut off the circulation by merely turning her head which surprised Dr. Capp at the time. The Tertiary assessment team could not detect it and labeled it “inconsistent”. It was not inconsistent; it was spectacular.
This compelling narrative was extracted for the Independent Medical Examiners Journal and talks about the stages Thoracic Outlet Syndrome being missed can go through:
This is a very specialized and controversial field and I am not impressed that there is anyone locally well versed in it; the above lady had seen some specialists who didn’t find a problem either.
3) Occipital neuralgia – causing severe headaches and pain back of head – I present a case of such missed in one of my other letter parts.
4) Other nerve entrapments – some of these when seen early just show irritate features rather than numbness. These will never be diagnosed at that state. They include: radial tunnel syndrome, superficial radial nerve compression near the wrist, tarsal tunnel syndrome, back cluneal nerve entrapments - are some compression missed by insurers.
5) Gluteal tears and bursitis – tears occur in 5-10% of people as they get older but are never diagnosed.
6) Posterior tibialis pains
7) Piriformis syndrome
8) Quadratus lumborum myofascial pain syndrome
9) Psoas myofascial pains
10) Myofascial Pain Syndromes - Any regional muscle pain syndrome because many don’t know how to examine for muscle knots.
11) Complex regional pain syndromes - this is were nerve damage causes sensory nerve to regurgitate irritating compounds (neurogenic inflammation) and this triggers blood vessel nerve pains. Easier for me to tell because their will be knots in muscles that just won’t go away.:
12) TMJ syndrome
13) T4 syndrome back
and so on
I do not have time to finish this – it would take too long. These are things missed by tertiary assessments and consultants.
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